Nontherapeutic Laparotomy Research Articles

Laparoscopy for Trauma and the Changes in its Use From 1990 to 2016: A Current Systematic Review and Meta-Analysis.

The role of laparoscopy in the diagnosis and treatment of stable abdominal trauma patients is still a matter of serious debate and only incomplete data are available. We performed a systematic review and meta-analysis of the literature between January 1990 and August 2016. Overall, 9817 laparoscopies were performed for abdominal trauma; only 26.2% of the cases were converted to a laparotomy. The incidence of therapeutic laparotomies showed a reduction from 69% to 47.5%, whereas the incidence of therapeutic laparoscopies increased from 7.2% to 22.7%.The overall perioperative mortality rate was significantly lower in the laparoscopy group [odds ratio (M-H, random); 95% confidence interval, 0.35 (0.26-0.48)]. The same group showed shorter length of hospital stay [odds ratio (M-H, random); 95% confidence interval, -3.48 (-8.91 to 1.96)]. This systematic review shows a significant decrease in the use of laparoscopy in trauma patients. Most likely the widespread use of imaging techniques allows a more accurate selection of patients for diagnostic laparoscopy. Infact, a reduction in incidence of nontherapeutic laparotomies is evident in these selected patients undergoing diagnostic laparoscopy. Moreover, the literature reported an increasing trend of therapeutic laparoscopy, demonstrating that it is safe and effective. The small number and poor quality of the studies identified, the retrospective observational nature of the studies (low level of evidence), the high risk of bias, and the high heterogeneity of some outcomes make the applicability of the results of this meta-analysis unclear.

Small bowel obstruction: need for surgery based on history and radiology

Background: Small bowel obstruction is a common clinical challenge because the proper management of small bowel obstruction requires a methodology which on one hand can promptly recognise the presence of strangulation-obstruction and hence the need for urgent operative intervention; and on the other hand, can avoid a non-therapeutic laparotomy along with its associated morbidities and further adhesion formation with its potential sequelae. The study was done to identify relevant features in the patient’s clinical and CT abdomen findings which when present would be highly predictive of the requirement of an operative intervention in a patient with small bowel obstruction.Methods: The study was a hospital based analytical observational study on patients admitted from March 2013 to May 2014 with a diagnosis of small bowel obstruction and who underwent a concurrent CT abdomen. Correlation of line of management was done with respect to the three chosen parameters, obstipation (history), mesenteric edema (CT imaging) and lack of small bowel feces Sign (CT imaging).Results: A total of 74 patients were included with Male:Female ratio being 3.1:1. Forty patients were managed conservatively and remaining underwent surgery with adhesions being the most frequent etiology. The most common operative procedure performed was adhesiolysis with or without band release. Twenty-three cases were performed by open method and remaining laparoscopically. Evaluation of the three parameters revealed that these variables, when present independently or in combination, are predictive for need for operative intervention (p-value <0.001). The sensitivity and specificity to predict the need for exploration when all 3 features were present concurrently was 38.24% and 100%, respectively.Conclusions: Small-bowel obstruction is a common surgical dilemma, the management of which is dealt on a daily basis by surgeons and non-surgeons. The management using variables based on history and radiology may help classify patients into those requiring conservative management and those in need of early exploration.

Characteristics and management of penetrating abdominal injuries in a German level I trauma center.

Penetrating abdominal injuries caused by stabbing or firearms are rare in Germany, thus there is lack of descriptive studies. The management of hemodynamically stable patients is still under dispute. The aim of this study is to review and improve our management of penetrating abdominal injuries. We retrospectively reviewed a 10-year period from the Trauma Registry of our level I trauma center. The data of all patients regarding demographics, clinical and outcome parameters were examined. Further, charts were reviewed for FAST and CT results and correlated with intraoperative findings. A total of 115 patients with penetrating abdominal trauma (87.8% men) were analyzed. In 69 patients, the injuries were caused by interpersonal violence and included 88 stab and 4 firearm wounds. 8 patients (6.9%) were in a state of shock at presentation. 52 patients (44.8%) suffered additional extraabdominal injuries. 38 patients were managed non-operatively, while almost two-thirds of all patients underwent surgical treatment. Hereof, 20 laparoscopies and 3 laparotomies were nontherapeutic. There were two missed injuries, but no patient experienced morbidity or mortality related to delay in treatment. 106 (92.2%) FAST and 91 (79.3%) CT scans were performed. Sensitivity and specificity of FAST were 59.4 and 94.2%, while those of CT were 93.2 and 85.1%, respectively. In hemodynamically stable patients presenting with penetrating abdominal trauma, CT is indicated and the majority of injuries can be managed conservatively. If surgical treatment is required, diagnostic laparoscopy for stable patients is feasible to avoid nontherapeutic laparotomy.

Conservative approach in drilling-cutting tool injuries

Objective: To prevent unnecessary laparotomies by evaluating the effectiveness of conservative approach in abdominal trauma cases due to drilling-cutting instruments. Methods: Demographic data, effected region of the body, additional findings of trauma, hemodynamic parameters, duration of admission, diagnostic methods and treatment modalities were retrospectively evaluated in 217 cases with abdominal injury (lower thoracic region, abdominal wall and back) among 1 128 victims with drilling-cutting instrument injuries between January 1, 2012 and December 31, 2017. The conservative approach was based on physical examination, hemogram follow-up and hemodynamic evaluation. Results: Totally 177 (81.6%) cases of 217 patients were followed conservatively while 25 cases were operated at early (1-8 hours) and 15 were operated at late (9-48 hours) periods. Two patients who underwent surgery in the early period and two patients who underwent surgery in the late period were accepted as negative laparotomy while 1 patient in the late operated group was regarded as non-therapeutic laparotomy. Diagnostic laparoscopy was performed in 81 cases. Complications developed in 7 patients who were operated in the early period and 10 patients who were operated in the late period. The mean hospital stay period was 5.3 days (1-33) in all cases, 4.5 days (2-20) in conservative treatment group and 8.4 days (3-33) in the operated patients; and the difference was statistically significant. Conclusions: Detailed physical examination, accurate assessment and effective use of different diagnostic methods reduce the frequency of negative and non- therapeutic laparotomies in abdominal stab wound injuries.

Diagnostic staging laparoscopy in gastric cancer treatment: A cost-effectiveness analysis.

Accurate preoperative staging helps avert morbidity, mortality, and cost associated with non-therapeutic laparotomy in gastric cancer (GC) patients. Diagnostic staging laparoscopy (DSL) can detect metastases with high sensitivity, but its cost-effectiveness has not been previously studied. We developed a decision analysis model to assess the cost-effectiveness of preoperative DSL in GC workup. Analysis was based on a hypothetical cohort of GC patients in the U.S. for whom initial imaging shows no metastases. The cost-effectiveness of DSL was measured as cost per quality-adjusted life-year (QALY) gained. Drivers of cost-effectiveness were assessed in sensitivity analysis. Preoperative DSL required an investment of $107 012 per QALY. In sensitivity analysis, DSL became cost-effective at a threshold of $100 000/QALY when the probability of occult metastases exceeded 31.5% or when test sensitivity for metastases exceeded 86.3%. The likelihood of cost-effectiveness increased from 46% to 93% when both parameters were set at maximum reported values. The cost-effectiveness of DSL for GC patients is highly dependent on patient and test characteristics, and is more likely when DSL is used selectively where procedure yield is high, such as for locally advanced disease or in detecting peritoneal and superficial versus deep liver lesions.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Gastric Adenocarcinoma: A Multimodal Approach.

Despite its declining incidence, gastric cancer (GC) remains a leading cause of cancer-related deaths worldwide. A multimodal approach to GC is critical to ensure optimal patient outcomes. Pretherapy fine resolution contrast-enhanced cross-sectional imaging, endoscopic ultrasound and staging laparoscopy play an important role in patients with newly diagnosed ostensibly operable GC to avoid unnecessary non-therapeutic laparotomies. Currently, margin negative gastrectomy and adequate lymphadenectomy performed at high volume hospitals remain the backbone of GC treatment. Importantly, adequate GC surgery should be integrated in the setting of a multimodal treatment approach. Treatment for advanced GC continues to expand with the emergence of additional lines of systemic and targeted therapies.

Criteres Du Traitement Non Operatoire Des Contusions Abdominales En Milieu Sous Equipe

The criteria of non-operative operative management (NOM) of blunt abdominal trauma remains poorly defined in the context of low-income countries. Purpose: To validate a protocol for blunt abdominal trauma by specifying indications for NOM in a resource-limited setting. Material and Method: The study was prospective, carried out over a period of 12 months at Sylvanus Olympio Teaching Hospital Lomé (Togo). It included all patients over 15 years admitted for abdominal blunt trauma. Patients were subjected to NOM or surgery according to systolic blood pressure, response to resuscitation measures, clinical examination, peritoneal tap, abdominal plain radiograph and ultrasound. Results: Sixty-four patients, including 53 men and 11 women, were admitted in the study. The mean age was 27.8 years. Road traffic accidents were the circumstance of the occurrence in all cases. Pneumopéritoneum was found in 3 patients (5.45%). Abdominal ultrasound identified a solid organ injury in 24 patients (43.6%). Spleen lesions were the most frequent injuries. An extra-abdominal lesion was present in 23 patients (35.9%). NOM was initiated in 52 patients (81.25%) and effective in 46 patients (88.4%). The failure of the NOM was due to small intestine perforation in 2 patients, a bladder injury in 1 patient, active bleeding in 1 patient and hemodynamic instability resulting in nontherapeutic laparotomy in 2 patients. Death was observed in 8 patients (12.5%), 2 of whom were in the NOM group. Conclusion: criteria for the NOM of blunt abdominal trauma can be defined according to the local possibilities. Early diagnosis of digestive perforation should remain a priority during clinical monitoring.

Reappraisal of Staging Laparoscopy for Patients with Pancreatic Adenocarcinoma: A Contemporary Analysis of 1001 Patients.

Recent advances in imaging and the increasing use of neoadjuvant therapy puts the contemporary utility of staging laparoscopy for patients with pancreatic adenocarcinoma (PDAC) into question. This study aimed to develop a prognostic score to optimize prevention of an unnecessary laparotomy and minimize the rate for unnecessary laparoscopy. Clinicopathologic data were evaluated for all patients undergoing surgical intervention for PDAC between 2001 and 2015, who were stratified into group 1 (2001-2008) and group 2 (2009-2014). The study identified 1001 patients eligible for analysis, 331 (33%) of whom underwent a staging laparoscopy before exploration. An unnecessary laparotomy was prevented for 44.4% of the patients in period 1 and for 24% of the patients in period 2 (p<0.001). Male gender [odds ratio (OR), 1.8; p<0.05], preoperative resectability (borderline resectable OR 2.1; p<0.019; locally advanced OR 7.6; p<0.001), CA 19-9 levels higher than 394 U/L (OR 3.1; p<0.001), no neoadjuvant chemotherapy (OR 2.7; p=0.012), and pancreatic body or tail lesions (OR 1.8; p=0.063) were predictive of occult metastatic disease. The developed scoring index demonstrated a c-statistic of 0.729. The observed-to-expected ratio for the index at every score level validated the index's model. A score cutoff at 4 was able to detect 76.1% of radiographically occult metastatic disease. The rate for unnecessary laparotomy among patients with PDAC has decreased in contemporary times, but unnecessary laparotomy still occurs for 1 in 4 patients. Using our scoring system, a cutoff of 4 allows 76% of radiographically occult metastases to be predicted, thereby selecting high-risk patients for laparoscopic biopsy and potentially avoiding a non-therapeutic laparotomy.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission

Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30-day mortality, postoperative duration of stay >30days, and complications. Patients >18years in The American College of Surgeons National Surgical Quality Improvement Program (2011-2014) who had 1 of 7 emergency operations between hospital day 3-18 were included. Patients with operations >95th percentile after admission (>18days; n=581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes. Of 10,093 patients with emergency operations, most were elderly (median 66years old [interquartile ratio: 53-77years]), white, and female. Postoperative 30-day mortality was 12.6% (n=1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11-18 compared with day 3-6 was associated with death (odds ratio 1.6 [1.3-2.0]), postoperative duration of stay >30days (odds ratio 2.0 [1.6-2.6]), and complications (odds ratio 1.5 [1.3-1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8-10.4]). Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only.

Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT)

Selective nonoperative management (SNOM) of abdominal gunshot wounds is being practiced in certain trauma centers, but its broader acceptance in the surgical community is unknown. We hypothesized that SNOM has been adopted in New England as an acceptable method of abdominal gunshot wound management. We reviewed the medical records of abdominal gunshot wound patients admitted from January 1996 to June 2015, in 10 New England Level I and II trauma centers. Outcomes included the incidence, success, and failure of SNOM, and morbidity and mortality related to SNOM. Of 922 patients, 707 (77%) received immediate laparotomy (IMMLAP) and 215 (23%) were managed by SNOM. Compared with IMMLAP patients, those with SNOM had a lower median Injury Severity Score (16 vs 8; p < 0.001), lower incidence of complications (34.7% vs 8.5%; p < 0.001) and mortality (5.2% vs 0.5%; p= 0.002), and shorter ICU and hospital stays (median days 1 of 8 vs 0 of 2, respectively; p < 0.001). One SNOM patient died after 3days due to a gunshot wound to the head. The overall incidence of SNOM increased from 18% before 2010 to 27% in the following years (p= 0.001). Eighteen patients (8.4%) had unsuccessful SNOM and underwent delayed laparotomy at an average of 12.5 hours (range 141 minutes to 48 hours) after arrival. Nine of them (4.2%) experienced complications that were not directly related to the delayed laparotomy, and none died. The rate of nontherapeutic laparotomies was 14.7% among IMMLAP and 5.5% among delayed laparotomy patients (p= 0.49). Selective nonoperative management of abdominal gunshot wounds, despite being a heresy only a few years ago, has now been established as an acceptable method of management inLevel I and II trauma centers in New England.

Minimally invasive staging of esophageal cancer.

Esophageal cancer is one of the most common malignancies in the world today and the sixth-leading cause of cancer-related mortality. Accurate preoperative staging of esophageal cancer is imperative to the selection of appropriate treatments. Patients with esophageal carcinomas typically undergo a multimodality staging process including noninvasive imaging techniques, such as computed tomography (CT) and positron emission tomography (PET), as well as endoscopic ultrasound (EUS), which is slightly more invasive. Minimally invasive surgical staging, with laparoscopy, occasionally in combination with video-assisted thoracoscopy, is used in the staging process at select institutions and has been shown to be more accurate than noninvasive staging modalities. Two major advantages of minimally invasive surgical staging over conventional techniques are the improved assessment of locoregional disease and enhanced identification of distant metastases. These advantages decrease the likelihood that the patient will undergo a nontherapeutic laparotomy. Currently, no clear consensus exists regarding which patients with esophageal cancer would benefit most from the addition of minimally invasive surgical staging. We have, however, found that minimally invasive surgical staging with laparoscopy is particularly valuable in detection of occult distant metastases. In this article, we summarize the staging modalities for esophageal cancer including minimally invasive surgical staging.

Role of diagnostic laparoscopy in the treatment plan of gastric cancer

To assess the clinical value of the diagnostic laparoscopy in choosing treatment strategies for patients with gastric cancer. Retrospective analysis was performed on clinical and pathological data collected from 2 023 patients undergoing gastric cancer surgery in the Zhongshan Hospital of Fudan University from 2009 to 2014. All the patients were diagnosed as gastric cancer by endoscopic biopsy and staged by imaging examination before surgery. During the diagnostic laparoscopy procedure, a small periumbilical incision was made and a pneumoperitoneum with CO2 under 10-15 mmHg was established through a port. A 10 mm trocar was put in, and the camera was inserted. Two 5 mm trocars were put in two ports which located in midclavicular line two fingers under the left and right costal margin and then the instruments were inserted. A thorough inspection included ascites, the abdominal cavity, liver, diaphragm, spleen, greater omentum, colon, small intestine, mesentery, adnexa (female) and pelvic floor. If the tumor located at the posterior part of the stomach, the gastrocolic ligament was opened in order to look for carcinomatosis in the omental bursa. The accuracy rate of diagnostic laparoscopy in diagnosing adjacent organ invasion and intra-abdominal metastasis was calculated, and the rate of adjusting treatment plans after diagnostic laparoscopy was also calculated. There were 52.7%(1 067/2 023) of patients underwent diagnostic laparoscopy. The accuracy rate of diagnostic laparoscopy in evaluating adjacent organ invasion and intra-abdominal metastasis were 98.3%(1 049/1 067) and 98.1%(1 047/1 067) respectively. Besides, 14 patients with stage T4b and 32 with intra-abdominal metastasis, which were missed by imaging examination, were diagnosed by diagnostic laparoscopy. The treatment plans of 9.3% (99/1 067) of patients were changed after diagnostic laparoscopy, and 65 (6.1%) cases of non-therapeutic laparotomy were avoided. However, 18 cases of adjacent organ invasion and 20 cases of intra-abdominal metastasis were still missed by diagnostic laparoscopy, and 12 cases received non-therapeutic laparotomy. Diagnostic laparoscopy has considerable value in assessing adjacent organ invasion and intra-abdominal metastasis and has great clinical significance in making precise treatment plans.

An investigation of bedside laparoscopy in the ICU for cases of non-occlusive mesenteric ischemia

BackgroundAcute mesenteric ischemia is a rare affection with high related mortality. NOMI presents the most important diagnostic problems and is related with the higher risk of white laparotomy. This study wants to give a contribution for the validation of laparoscopic approach in case of NOMI.MethodsThirty-two consecutive patients were admitted in last 10 years in ICU of Paolo Giaccone University Hospital of Palermo for AMI. Diagnosis was obtained by multislice CT and selective angiography was done if clinical conditions were permissive. If necrosis was already present or suspected, surgical approach was done. Endovascular or surgical embolectomy was performed when necessary. Twenty NOMI patients underwent medical treatment performing laparoscopy 24 h later to verify the evolution of AMI. A three-port technique was used. In all patients we performed a bed side procedure 48–72 h later in both non-resected and resected group.ResultsIn 14 up 20 case of NOMI the disease was extended throughout the splanchnic district, in 6 patients it involved the ileum and the colon; after a first look, only 6 patients underwent resection. One patient died 35 h after diagnosis of NOMI. The second look, 48 h later, demonstrated 4 infarction recurrences in the group of resected patients and onset signs of necrosis in 5 patients of non-resected group. A total of 15 resections were performed on 11 patients. Mortality rate was 6/20–30% but it was much higher in resected group (5/11–45,5%). Non-therapeutic laparotomy was avoided in 9/20 patients and in this group mortality rate was 1/9–11%. No morbidity was recorded related to laparoscopic procedure.ConclusionsLaparoscopy could be a feasible and safety surgical approach for management of patient with NOMI. Our retrospective study demonstrates that laparoscopy don’t increase morbidity, reduce mortality avoiding non-therapeutic laparotomy.

Laparoscopy in Management of Blunt and Penetrating Abdominal Trauma: Single Center Experience

Introduction: Exploratory laparotomy in either blunt or penetrating abdominal trauma with suspected intra-abdominal injuries is associated with a high negative (non-therapeutic) laparotomy rate and a high procedure-related morbidity. In abdominal trauma, laparoscopy may be used either as a diagnostic or therapeutic tool in hemodynamically stable patients. Laparoscopy can avoid unnecessary (non-therapeutic) laparotomy and may allow laparoscopic repair of these injuries. Diagnostic laparoscopy can reliably rule out a significant intra-abdominal injury in patients with equivocal abdominal examination following trauma. In sharp abdominal trauma laparoscopy has been shown to be very effective in determining violation of the peritoneal cavity by tangential wounds. Patients and methods: 38 patients with abdominal trauma were enrolled for this study. Exclusion criteria for all patients included; hemodynamic instability, clinical or radiological evidence of major abdominal organs or vascular injuries, posterior abdominal wall penetrating injuries, bowel evisceration, evidence of 2 thoracic injuries (as pneumothorax), or head injuries. Pneumo-peritoneum is achieved with low CO flow and maintained at low pressures (10–12 mmHg). We started by exploration of abdominal cavity and suction of the free blood from the peritoneal cavity. In sharp injuries, inspection of the peritoneal membrane was done for evidence of penetration. Small hepatic and splenic hematomas were left undisturbed. Small and accessible tears ware sutured. Deep or inaccessible liver and splenic tears needed conversion to laparotomy. Small intestinal simple tears were sutured laparoscopically while complex tears needed laparotomy conversion. Left colonic tears needed laparotomy conversion and colonic diversion. Results: Patients with blunt trauma (26 patients), in whom laparoscopic management was completed were18 patients (69%). 5 patients (26%) of the later, had negative laparoscopic exploration, for which the operations were terminated, 6 patients (37%) had retroperitoneal hematomas with free hemo-peritoneum, 2 cases (10.5%) showed only right hepatic lobe small sub-capsular hematomas, 3 cases (16%) showed small liver tears, and 2 cases (10.5%) showed small splenic sub-capsular hematomas and small superficial tear. All the previous injuries were left undisturbed with laparoscopic suturing of the 2 cases with liver tears. 12 cases (31.5%) with sharp penetrating anterior abdominal wall trauma were included in this study. The cases with penetrating abdominal trauma that could be completed laparoscopically were 8 cases (67%) and those who needed laparotomy conversion were 4 cases (33%). The mean operative time in the cases that were completed laparoscopically was 85 minutes and in the laparotomy converted group was 67 minutes. Analysis of postoperative pain in all patients was done using the Numeric Rating Scale (NRS) for pain. Pain was subjectively more severe and statistically different in the laparotomy group than laparoscopic group. The range of hospital stay in the laparoscopy group was 2 to 5 days, and in the laparotomy group it was from 6 to 8 days. No cases in the laparoscopy group showed wound infection; while it was 3 cases (25%) in the laparotomy converted group. Long term follow up showed one case (8.3%) in the laparotomy group developed incisional hernia related to the main abdominal wound, while no similar case was detected in the laparoscopy completed group. Conclusion: The evaluation and management of abdominal trauma are multi-factorial. Careful selection of trauma patients, high index of suspicion, and a low threshold for laparotomy will provide them the benefits of laparoscopic management and reduce the rates and morbidity of unnecessary laparotomy.

Selective Non Operative Management of Blunt Liver Trauma: Is It Still a Challenge?

The non-therapeutic laparotomy in managing cases with blunt liver injuries is not without risks, so selective non-operative treatment in stable patients was tried in many centers and has become the standard of care of these patients The aim of this study was to assess the feasibility and safety of selective non-operative management of blunt liver injury in our institution <i>Patients and Methods:</i> This prospective study was conducted on 40 patients with blunt liver injury who met our inclusion criteria admitted to Tanta University Hospital during the period from January 2012 to January 2014. All patients were treated by selective non-operative treatment (repeated clinical examination, serial U/S and CT study and follow up) <i>Results:</i> The age of our patients ranged from 26 to 40 years with a mean (±SD) of 31.3 ± 3.77 years. 36 patients were males (90%), while 4 patients (10%), were female. Total length of stay was ranged from 2 days to 15 days with a mean (±SD) of 5.8 ± 3.27 days as regards all cases. Intensive care unit stay was in 2 cases (5%) which FNOM with mean (±SD) of 1.5 ± 0.7 days. CT study was done in all cases (100%), 2 cases (5%) was operated after 6 hours of conservatism in ICU due to hemodynamic instability after initial assessment of stability. <i>Conclusions:</i> Selective non operative management of blunt liver injury in bunt abdominal trauma is safe, efficient, and cost-effective in the appropriate clinical setting and can lead to fewer unnecessary laparotomies in patients with liver injury. Proper patient selection, resources that permit close observation, and frequent abdominal examinations are paramount in obtaining the best results.

Penetrating abdominal stab wounds – current practice and recommendations

This retrospective study reviews current practice in managing penetrating abdominal stab wounds in our centre and evaluates patients who can be safely managed non-operatively. The records of patients admitted to Rashid Hospital with isolated abdominal stab injuries from January 2011 to December 2015 were reviewed. We reviewed the patients’ demographic data, clinical findings, diagnostic tests and surgical interventions. Patients were eligible for inclusion if they had a penetrating stab injury and fulfilled the criteria for conservative management (i.e. were haemodynamically stable, with localized tenderness and no evisceration). Patients were excluded if they were haemodynamically unstable or had evisceration and generalized tenderness. A total of 66 patients with abdominal stab wounds were admitted between January 2011 and December 2015; 44 of these had penetrating injuries. The mean age of the patients was 28 years; 62 (94%) were men and four (6%) were women. A total of 29 patients fulfilled the inclusion criteria, but only six were treated fully conservatively. Twenty-three (35%) patients underwent surgery; 13 (57%) procedures were non-therapeutic and 10 (43%) were therapeutic. Selective non-operative management for stable patients without signs of peritonitis is an effective tool for decreasing the number of unnecessary laparotomies, but this should be practised in a specialized trauma centre and performed by experienced clinicians (preferably by the same team). The use of triple-contrast abdominal computerized tomography can reduce the rate of negative findings at laparotomy. Diagnostic laparoscopy is safe and decreases both the requirement for non-therapeutic laparotomy and length of hospital stay.

Laparoscopy in Abdominal Trauma

Exploratory laparotomy is the traditional therapeutic approach in patients with abdominal trauma. However, due to potential associated morbidity and mortality, avoiding unnecessary laparotomies is an important issue. While selective nonoperative management has shown good results, certain clinical situations in hemodynamically stable patients, where the need for surgery could be in doubt, call for proactive diagnosis. In these cases, laparoscopy can be used to exclude or diagnose potential injuries requiring surgery. When the surgeon has the necessary expertise, some of these injuries can be treated laparoscopically. Over the last decades, diagnostic and therapeutic applications of laparoscopy have increased, with reported reduction in nontherapeutic laparotomies. Furthermore, shorter duration of hospital stay, faster recovery, and reduced costs have been reported. However, as seen in other minimally access interventions, safe implementation of laparoscopy in trauma care requires adequate surgical training and skills as well as appropriate staffing and equipment.

Factors associated with adverse events after emergency laparotomy in Cape Town, South Africa: identifying opportunities for quality improvement

BackgroundSurgical outcomes research is limited in areas of the world with the greatest unmet surgical need and likely greatest variation in outcomes. Measurement alone may improve outcomes—the so-called Hawthorne effect. The purpose of this multicenter cohort study was to identify factors that are both feasible to collect and are associated with a major adverse event following a targeted procedure in Cape Town, South Africa. MethodsA collaborative of four acute care surgical units was formed to develop a data set with minimal data burden describing outcomes after an emergency exploratory laparotomy during a 3-mo period (February-April 2015). Controlling for patient, problem, provider, procedure and process predictors, multivariate models were built to identify risk factors for a major adverse event and higher resource use after surgery in our collaborative. ResultsThe outcomes of 450 exploratory laparotomies from the four participating hospitals were audited, 319 (70.9%) were for non-trauma and 131 (29.1%) were for trauma. The major adverse event rate was 15.7% (95% CI 12.6-19.4). In the multivariate analysis, factors associated with the primary outcome included age, American Society of Anesthesia score of greater than 2, bowel resection, preoperative CT scan, and a nontherapeutic laparotomy. A major adverse event was associated with all three outcomes assessing increased resource utilization. ConclusionsThis study supports the comparative outcome assessment of a high-volume or high-risk procedure as a proxy for measuring the quality of care provided in a surgical collaborative. Such an exercise can identify opportunities for quality improvement.

The role of laparoscopy in management of stable patients with penetrating abdominal trauma and organ evisceration.

Organ evisceration after penetrating abdominal trauma (PAT) carries a high rate of significant intra-abdominal injuries. There is uniform agreement that organ evisceration warrants immediate laparotomy. Nonoperative management of stable asymptomatic patients with evisceration is associated with a high failure rate. Most authors exclude patients with organ evisceration from laparoscopic management.The aims of this study were to determine the significance of organ evisceration in stable patients with PAT and to assess the feasibility of laparoscopic management of this group. Intraoperative findings, performed surgery, and complications in stable patients who underwent laparoscopy for PAT and evisceration between January 2012 and December 2014 were retrospectively analyzed. All unstable patients underwent laparotomy and were excluded. A total of 189 stable patients were treated with laparoscopy for PAT. Thirty-nine patients (20.6%) had organ evisceration; 37 patients had stab wounds and 2 patients had gunshot wounds. Fifteen patients had bowel evisceration and 24 had omental evisceration. In total, 25 patients (64%) had significant injuries (colon, small bowel, etc.) and required therapeutic laparoscopy. The rate of therapeutic laparoscopy was 73% in patients with bowel evisceration and 58% in patients with omental evisceration. This difference was not statistically significant. The most commonly injured organ was the small bowel. The small-bowel repair, resection, and anastomosis were the most commonly performed procedures. We did not have any missed injuries. There were neither conversions nor significant complications in the postoperative period. Fourteen patients avoided nontherapeutic laparotomy. Organ evisceration in stable patients with PAT is associated with a high rate of significant intra-abdominal injuries and mandates abdominal exploration. Laparoscopic management is feasible, has a high accuracy in identifying intra-abdominal injuries, provides all benefits of minimal invasive surgery, and avoids nontherapeutic laparotomy. Therapeutic study, level V.